Health

Summary

C's spouse (A) had advanced kidney cancer which had spread to their brain. A was admitted to hospital after they developed breathing problems. They were diagnosed with a pulmonary embolus (blood clot in the lung). A agreed for the pulmonary embolus to be treated in hospital, in the hope that they could be discharged once stable, but their condition deteriorated and they died in hospital.

There was a period during A's admission when their medication was stopped while clarification was sought as to their treatment plan. C complained about the clinical decision-making regarding A's care and treatment. C considered that failings in A's care and treatment led to their death in hospital, denying them of the right to be cared for at home. C also complained about the board's communication.

We took independent advice from a consultant physician. We noted how difficult this case was, in particular from the perspective of the family. Although we noted certain areas of care that could have been better, we considered that overall the standard of care and treatment was reasonable and that A was nearing the end of their life by the time of their admission. We did not consider that the outcome would have been different had there not been a period of time during which medication was withdrawn pending clarification of A's treatment plan. Therefore, we did not uphold this complaint.

We noted that a number of physicians were involved in A's care and treatment and that there had been a degree of uncertainty about A's treatment plan. Although some aspects of communication could have been better, we considered that the clinicians did their best to communicate to A's family how ill A was and to have appropriate discussions with them around resuscitation and escalation. Therefore, we did not uphold the complaint about communication.

Summary

C complained about the treatment that they received from the practice during a three year period. C had repeatedly reported symptoms of a cough and breathlessness and was prescribed an inhaler but it took a number of years until they were diagnosed with Sjogren's syndrome (a condition which affects parts of the body that produce fluids like tears and spit (saliva)). C believed that action should have been taken by the GP at the practice to arrive at the diagnosis sooner.

We took independent advice from a clinician and found that the GP had provided C with appropriate medical treatment in view of the reported clinical symptoms and that they made a timely referral to hospital specialists. Although C was subsequently diagnosed with Sjogren's syndrome, this was not as a result of a failing in the treatment provided by the practice. We did not uphold the complaint.

Summary

C complained to the board about the care and treatment which their late parent (A) received at the A&E at Glasgow Royal Infirmary. A had presented as an emergency following them taking too much medication. A was not admitted to hospital but was discharged home and advised to take Codeine (a sleep-inducing and analgesic drug derived from morphine). A died shortly after their discharge from hospital.

We sought independent clinical advice from a professional adviser. We found that apart from a failure to complete some initial observations, staff in A&E performed appropriate investigations and that it was clinically appropriate to discharge A from hospital. There was no indication from the clinical records that staff had prescribed A Codeine on discharge or that this was said to them. We did not uphold the complaint.

Summary

C complained to us on behalf of their parent (A) who has dementia. A was admitted to Glasgow Royal Infirmary (GRI), after falling at home. A's condition improved and they were discharged home. After a few days, A was readmitted to GRI and treated for pneumonia (inflammation in the tissue of the lungs). Although A responded well to the treatment, their family was concerned about their mobility and pain when moving. A was referred for imaging of their pelvis and hip, which did not find a skeletal injury. Later that month, A was transferred to Stobhill Ambulatory Care Hospital. Around a week later, A was given a lumbar x-ray, which found a vertebral wedge fracture (a fracture of the bones commonly called the lower back). C raised concerns about A's medical care and their nursing care at both hospitals.

We took independent advice from a consultant physician in geriatric medicine (a specialist in medicine of the elderly). We did not consider that there was an unreasonable delay in carrying out A's lumbar x-ray. In particular, we found that it was appropriate that the medical staff had focused on ruling out A having fractures that might be treatable with surgery. We did not uphold this aspect of C's complaint.

We also took independent advice from an acute nursing specialist. We found that A's pain was not assessed appropriately, as nursing staff did not use the correct tool for someone with cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). We also found that A fell at a time that they should have been under enhanced supervision by nursing staff due to their high risk of falls. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients with cognitive impairment should have their pain levels assessed using an appropriate tool so it can be managed appropriately.
• When patients are considered to require enhanced observations in a cohort room, there should be appropriate nursing staff (in terms of both skill mix and staffing levels) to implement this.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C made a complaint on behalf of their partner (A), who had a cancer diagnosis. C complained that there was a failure to keep A reasonably informed about appointments for treatment. C considered that the board had failed to ensure that they had A's address correctly recorded on the patient database. C also raised concerns about a delay in responding to the complaint, and a failure to provide a consistent explanation about why A was not reasonably informed of appointments for treatment.

We found that the board were able to provide copies of letters with the correct address, and whilst these had not been received by A, it was not possible to say that they had not been sent. In addition, whilst A turned up for an appointment that A did not know had been cancelled, the consultant did see A to carry out a full consultation. We did not uphold this aspect of C's complaint.

We found that the board provided conflicting accounts of what address information was held on the databases for C and for SPSO and whether or not this required to be corrected/had been corrected.

We also found that there was a delay in responding to C's complaint. We noted that the complaints department had moved, but we considered that it was reasonable to expect that the board would have in place a mechanism to forward the mail addressed to the complaints department to the new location within a reasonable period of time. We upheld these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for (i) a failure to ensure they had correctly recorded on their patient databases A's address which he had lived at since August 2015, (ii) a failure to provide a response to C's complaint within a reasonable period of time and (iii) a failure to provide a consistent explanation regarding why there was a failure to ensure A was reasonably informed of appointments for treatment. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Ensure patient addresses are accurate on all databases.

In relation to complaints handling, we recommended:

• Ensure complaint correspondence received is directed to the correct department.
• Ensure a thorough investigation is carried out before a stage 2 response is sent to a complainant.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment their family member (A) received from the board.

A had a complex medical history and received treatment in hospital on a number of occasions. C became aware that a wound that A had on their leg had deteriorated. C was very concerned about the condition of the wound.

C complained that, although A had been in and out of hospital on a number of occasions, the board had failed to take reasonable steps to treat A's leg wound. They complained that A was discharged from hospital on multiple occasions following treatment for infections, but that follow-up arrangements were inadequate and, as a result, the leg wound was left to deteriorate. C said that A had suffered both physically and mentally and that family members had been extremely distressed seeing A suffer.

We found that A's complex medical history meant that they had multiple hospital admissions and that they were seen regularly by community based district nurses and tissue viability nurses. A's wounds were quite severe and were complicated by the fact that their condition caused their leg muscles to contract, keeping the two skin surfaces together and difficult to access for pressure-relieving treatment. There was no suggestion that the wound on A's leg was caused, or made worse, by any shortfall in the care and treatment provided by the board.

We were satisfied that staff caring for A were aware of their wounds and made efforts to relieve the discomfort that they caused as well as working towards helping them to heal. Upon each admission to hospital, A's wounds were assessed and a referral was made to the tissue viability service for review. Whilst on some occasions A was discharged home before the review could occur, they continued to receive care at home from the community tissue viability nurses.

Whilst overall we were satisfied that A's wounds were taken seriously and a management plan was in place, we found that some discharge documentation was incomplete and that communication between the hospital and community based teams was lacking at times. As such, the most up-to-date review information from the acute tissue viability service may not have been communicated to the community nurses who provided the regular care that A required. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Consider holding a multi-disciplinary team meeting to discuss how to improve communication between teams and provide a holistic approach to care for individuals with multiple needs.
• Remind all appropriate staff of the importance of completing all discharge documentation and wound care charts.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment of their late parent (A) who died in Glasgow Royal Infirmary (GRI) from respiratory failure and an undiagnosed progressive neurological condition. Potential Motor Neurone Disease (MND, a rare condition that progressively damages parts of the nervous system) had been noted by a neurology registrar five months earlier but this diagnosis was never confirmed. A was admitted to GRI four times over the following months, and C complained that their rapidly deteriorating condition was not acted upon and that palliative care was not initiated.

We took independent advice from a consultant neurologist (a specialist in nerves and the nervous system, especially of the diseases affecting them), who noted that investigations planned by the neurology registrar were not followed up, and that a referral to a specialist neuropathy clinic was not fulfilled, within national waiting time targets. We found that the medical teams caring for A during their hospital admissions failed to consider a neurological disorder as the cause of their deterioration and failed to seek specialist neurological input. We considered that neurological clinical standards should have been applied regardless of the absence of a confirmed diagnosis, and this would have included a timely assessment of communication, nutritional and respiratory needs. Notwithstanding this, we found that the palliative symptom treatment offered to A in the last months of their life was of a reasonable standard and, despite the absence of a diagnosis, we saw no evidence that A suffered from a lack of care or treatment. On balance, however, we upheld this complaint.

C also complained that the family were not informed that A's condition was terminal. We did not consider that staff were in a position to predict A would die when they did, given the lack of clear neurological diagnosis, and we were satisfied that there was communication with the family when death was appreciated to be imminent. However, the failure to seek specialist neurological input meant that there was a missed opportunity to clarify the diagnosis and enable clearer communication with the family regarding the prognosis. C also complained that the board failed to explain why a post mortem (PM) was not deemed necessary when A's deterioration and death was viewed as sudden. While we did not consider that a PM would have identified the underlying cause of A's neurological deterioration, we noted that it would have been best practice to discuss this with the family and seek their views before reaching a decision regarding a PM. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family that the failure to seek specialist neurological input meant there was a missed opportunity to clarify A's prognosis and enable clearer communication with them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for failing to ensure planned investigation was carried out within National Waiting Time Guidance; for the failure to seek a specialist neurological opinion during A's hospital admissions; and for the failure to apply the Neurological Standards regardless of the absence of a confirmed diagnosis.

What we said should change to put things right in future:

• An effective handover of care should take place, and planned referrals should be followed up, when a clinician moves on to a different role / their role in providing a patient's care has ended.
• The board should consider their processes for ensuring maximum waiting times from diagnosis to treatment are adhered to, where possible, particularly in regard to patients who have progressive neuromuscular disease.
• The board should provide education to respiratory and emergency physicians to ensure they are aware of the potential contribution of neuromuscular weakness to respiratory failure in emergency situations, how to recognise this and how it can be managed effectively.
• The board should reflect on the view that the Neurological Standards would have been appropriate in this case, regardless of the absence of a confirmed MND diagnosis, and feed this back to relevant staff in a supportive manner to ensure that current standards are applied, where appropriate, in future.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C brought a complaint about the care and treatment that their late spouse (A) received during three admissions to Aberdeen Royal Infirmary. C was concerned that A did not receive appropriate treatment and was discharged on each occasion. A was initially admitted following a heart attack, and died a few months later due to heart failure.

We took independent advice from a consultant cardiologist (medical specialist dealing with disorders of the heart). We found that the care and treatment A received during two of these admissions was reasonable, including the decision to discharge A. However, during one admission the board acknowledged that there was a missed opportunity to provide cardiology input and seek an in-patient echocardiogram (a heart scan that uses sound waves to create images).

We found that it was unreasonable that no input was sought from the cardiology department during this particular admission and that an opportunity was lost to make the correct diagnosis and to optimise possible treatment options. We upheld the complaint but also noted that it was not possible to say definitively whether this would have changed A's survival prospects.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not seeking input from the cardiology department during A's admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Input should be sought from the cardiology department where a patient has reduced cardiac function following a recent history of heart attack.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their child (A) about the service received from the practice and the way in which their complaint was handled.

A commenced a course of treatment with the practice because due to a dental overjet (when the upper teeth protrude outward and sit over the bottom teeth), they qualified for NHS funding. A and C agreed to proceed with a functional appliance to correct the overjet. A wore the appliance some of the time, but they did not comply with the treatment in full. A was warned of the necessity to comply and given several reminders. A also missed an appointment.

C was sent a 'wish to continue' letter in which they were advised that they should get in touch within four weeks or A would be discharged back to the dentist. C contacted the practice within this period of time to discuss other options for A. As C did not receive a response, they raised a complaint. During this period A was discharged back to the dentist.

We took independent advice from an orthodontist. We found that, although it is accepted that the clinical decision may not have been different, we considered there should have been a further clinical discussion before A was discharged. We upheld this aspect of C's complaint.

In relation to the complaint handling, we upheld this complaint on the basis that there was a delay in responding to C's concerns in full and C was not signposted to this office.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failing to have a clinical discussion with them, prior to discharging A, for a delay in responding to the complaint, for failing to provide a clinical explanation why A was discharged when C was trying to engage in discussions regarding A's future treatment and failing to signpost to this office. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The practice should engage in clinical discussion before discharging the patient, when a patient or their representative asks to discuss clinical treatment within the timeframe set by the practice.

In relation to complaints handling, we recommended:

• To ensure a full explanation is provided to a complaint, with input from clinical staff, within a reasonable time, and that a complainant is signposted to this office.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the treatment which their partner (A) received when they attended their GP practice with confusion and could not walk unaided. A could not provide a urine sample and was given a prescription for antibiotics. A collapsed in the car park following the consultation and was taken to hospital. C believed that the GP should have arranged a hospital admission for A. The practice felt that appropriate clinical treatment had been offered.

We took independent clinical advice from a professional adviser. We found that the GP had carried out an appropriate assessment of A and had diagnosed A as having an infection and therefore prescribed alternative antibiotics with advice to seek further medical advice should their condition deteriorate. It could not have reasonably been foreseen that A would collapse shortly after leaving the GP practice. We did not uphold the complaint.